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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320433
Report Date: 09/25/2025
Date Signed: 09/25/2025 01:46:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2025 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250918085423
FACILITY NAME:OCEANVIEW LIVING OF SAN PEDROFACILITY NUMBER:
198320433
ADMINISTRATOR:SABINA NAYBERGFACILITY TYPE:
740
ADDRESS:2100 SOUTH WESTERN AVENUETELEPHONE:
(310) 548-0625
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY:86CENSUS: 50DATE:
09/25/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Gloriella Jara, AdministratorTIME COMPLETED:
01:56 PM
ALLEGATION(S):
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Facility staff failed to ensure proper wound care for a resident with multiple open wounds.
INVESTIGATION FINDINGS:
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On 09/25/25 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, visit to investigate the allegations listed above. LPA was met by staff one, Gloriella Jara - Administrator (S1) and the purpose of the visit was explained.
The investigation consisted of the following; On 09/25/25 LPA requested and reviewed resident and staff rosters and two (2) residents’ face sheet(s) and physician’s report (R1-R2). LPA also requested staff training(s) and personnel record(s) of two (2) staff (S2-S3) who are to provide care management. LPA reviewed crossover notes for the dates of 09/19/25 through 09/25/25. LPA interviewed three (3) residents (R1-R3) and two (2) staff (S1-S2).
The investigation revealed the following:
Regarding the allegation, “Facility staff failed to ensure proper wound care for a resident with multiple open wounds.”, it is being alleged that a resident is not receiving proper wound care during their stay.

Report continues, please see LIC-9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20250918085423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OCEANVIEW LIVING OF SAN PEDRO
FACILITY NUMBER: 198320433
VISIT DATE: 09/25/2025
NARRATIVE
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Record reviews revealed the following; all residents' medical assessment (R1-R3) have been marked not to have any infectious disease. S2 and S3 have conducted required training for their specific job role, yet there are no crossover notes regarding a resident in care nor any notes as having a resident being relocated to any hospital. LPA interviewed three (3) residents (R3-R5) and all three (3) residents feel their medical needs have not been met. LPA interviewed two staff who were unaware of the current status of a resident (R1). Based on LPA's interviews conducted and records review, there is enough evidence to support the above allegation. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), chapter six (6) is being cited on the attached LIC9099D. Please see LIC9099D.

There has been one (1) deficiency cited during today's visit, please see LIC9099D. There has been one (1) technical assistance provided, please see LIC9102TA.

An exit interview and a copy of this report, appeals rights and the deficiency cited have been provided to Gloriella Jara - Administrator (S1).

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250918085423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OCEANVIEW LIVING OF SAN PEDRO
FACILITY NUMBER: 198320433
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2025
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical,..needs. When changes in...physical health..., the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician...if any.
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Administrator and LPA have agreed that documentation in crossover notes are to be recorded for any changes in physical, mental, emotional and social functioning of the residents in care. LPA has also requested the facility to forward any special incidents (LIC624) that take place
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This has not been met as evidenced by LPA's interviews and record review, the licensee did not ensure that a change in R1's physical need(s) have been reported to R1's physician which poses a potential health risk to residents in care.
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during residents' stay at this facility. Administrator will forward all relevent documentation of this training, signed and dated by staff present, including those who presented the information, via email, to MARIO.LEON@DSS.CA.GOV
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3